Presented by Aileen E. Wetzel, Associate Director CMA Center for Economic Services

1. Medical Oncology Association of Southern California December 1, 2010 Know Your Rights: How to Identify and Stop Unfair Payment Practices Presented by Aileen E. Wetzel, Associate Director CMA Center for Economic Services

2. Today We’ll Discuss: • CMA Resources to assist your practice • Important California laws that protect • physicians • Filing a Formal Complaint

3. CMA Resources • CMA On-Call • Sample document and Index in your handouts • CMA Practice Resources (CPR) - Monthly e-bulletin full of tips and tools to empower practices • CMA Alert – Bi-weekly newsletter on important issues that affect physician practices Sign up for CPR and Alert at www.cmanet.org/news/cpr

4. CMA Resources - Continued • CMA Toolkits -Free downloads for members only • “Taking Charge: A step-by-step guide to contract negotiations” • “Back to Basics: A step-by-step guide to maximizing your cash flow” • Payor Profiles • Mini-toolkits (e.g. Contract Amendment Guide for Physicians) • Know Your Rights (e.g. Unfair Payment Practices, Time Frames for Appeal, etc.) • Educational Webcasts • Reimbursement Helpline (888) 401-5911 • Center for Economic Services website www.cmanet.org/ces

5. Fee Schedule/Payment Rule Disclosure and Amendments • Payers must fully disclose complete fee schedules and payment rules • Material modifications to contract, including changes to fee schedule, require 45 days advance notice to physician with the right to terminate the contract if physician is not in agreement with change CMA member resources: On-Call documents #1020 & #1070; Contract Amendments: An Action Guide for Physicians

6. What Are the Claim Filing Deadlines? • Timeframe to submit claims cannot be less than: • 90-days for contracted physicians • 180-days for non-contracted physicians There is a “good cause” exception! • Payers must verify receipt of claims • 2-days for electronic • 15-days for paper • Payers must forward misdirected claims (specific to HMO claims) • Within 10-days CMA member resources: On-Call documents #0146 & #1070

7. When Does My Claim Need to be Paid, Contested or Denied? • HMOs – 45 working days • PPOs – 30 working days • ERISA – 30 calendar days • Medi-Cal & Medi-Cal Managed Care - 30 calendar days • Medicare – 30 calendar days • Workers’ Comp – 45 working days • Remember, the clock doesn’t start ticking until the payor receives a CLEAN claim. • CMA member resource: Know Your Rights- Timely Payment

8. What Are the Penalties For Late Payment? CMA member resource: On-Call document #0124 & Know Your Rights: Timely Payment

9. What Are the Appeal Timeframes? CMA member resources: Know Your Rights: Timeframes to Appeal & Know Your Rights: Quick Guide for Appeals

10. I Obtained a Prior Authorization But the Payor Denied Payment… • Once an authorization is obtained, plans and insurers are prohibited from rescinding or modifying the authorization after the physician renders the service in good faith and pursuant to the authorization. • If care is authorized, physicians must be paid even if the plan/insurer made a mistake or the patient was not covered or eligible for the specific services provided. • Violations should be reported to the regulator and CMA!! CMA member resource: On-Call document #0145

11. Requests for Refunds • Requests for refunds must be made in writing within 365 days of the date of payment • Overpayment notices to physicians must identify: • Patient name • Date of service • Amount payer believes was overpaid • Reason for overpayment • Disputes must be made in writing within 30 working days • Payer must process the dispute and respond prior to offsetting CMA member resource: On-Call document #0135

12. Filing a Formal Complaint • Take Action • Appeal to the payor • Identify the regulator (see the May issue of CPR for a discussion on “Which Laws Apply” to determine the appropriate regulator) • Prepare your complaint • File your complaint • Notify CMA CMA will help members file a formal complaint! • CMA resource: On-Call document #1051

13. CMA Can Help! • CMA’s members-only reimbursement helpline (888) 401-5911 • CMA’s Center for Economic Services website: www.cmanet.org/ces • CMA’s member services helpline (800) 786-4CMA (4262)